Medical Coder; Inpatient

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Contractor - 1099 Professional Jersey City, NJ, US

Salary Range: $20.00 To $40.00 Hourly

Role Overview

The Medical Coder (IP) is responsible for accurately assigning ICD-10-CM/PCS diagnosis and procedure codes for inpatient hospital services. This role ensures coded data is complete, compliant, and supports appropriate reimbursement, quality reporting, and regulatory requirements.

Key Responsibilities

• 100% REMOTE
• At least 5 years of IP PCS Coding experience, required
• CCS certificate from AHIMA is required.
• System
  
  Experience:
  
  Cerner | Power Chart | 3M
• Start Date:
  
  Immediately
• Per case pay rate
• Must complete and pass an IP coding assessment test and successfully code 5 charts.

Medical Coding

• Review complete inpatient medical records to accurately determine the principal and secondary diagnoses, procedures, and complications
• Assign accurate ICD-10-CM and ICD-10-PCS codes for diagnoses and procedures
• Accurately sequences diagnoses and procedures
• Ensure documentation supports MS-DRG assignment and severity of illness (SOI) and risk of mortality (ROM)
• Strive to obtain the optimal DRG assignments on each medical record coded with assistance of computer system
• Apply official coding guidelines, UHDDS definitions, and payer-specific requirements
• Query providers for clarification when documentation is incomplete, inconsistent, or unclear
  • Appropriately hold accounts when more information is required for accurate code/DRG assignment
  • Contact appropriate staff, leadership or medical staff as needed
• Meet established productivity and accuracy benchmarks
  • Demonstrate a consistent level of productivity and performance
  • Code a minimum of 2 inpatient charts per hour
  • Maintain a monthly coding accuracy and DRG accuracy rate of 95% or above
• Collaborate with CDI, compliance, and billing teams to resolve coding issues
• Participate in internal audits, external audits, and education initiatives
• Works as a team member to meet department and client specific goals
• Complete all assignments in conscientious and reliable manner

Compliance

• Ensure compliance with ICD-10-CM/PCS, MS-DRG/APR-DRG, and payer specific requirements
• AHA official coding guidelines, coding clinics, CMS and AHIMA standards of ethical coding, and other regulatory standards
• Client-specific coding guidelines, policies and procedures except when in conflict with official coding guidelines
• Maintain confidentiality and comply with HIPAA regulations

Education & Training

• Regularly reviews coding literature to stay current on new or revised coding guidelines
• Maintains appropriate certifications from AHIMA/AAPC
• Expresses interest in and pursues continuing education

Perform additional duties as assigned and assist with other tasks as requested.

Required Skills & Qualifications

Experience:

• Minimum of five (5) years of HIM and inpatient facility coding experience

Education:

• Associates degree required in Health Information Management, Healthcare Administration, other healthcare related fields, or Business Administration or Management, Bachelor's degree preferred
• Candidates with significant relevant experience and demonstrated expertise may be considered in place of formal educational requirements.

Credentials/

Certifications:

• CCS required
• Additional credentials preferred (RHIA, RHIT, CCS-P, CPC, CPMA, COC, CIC, CRC)

Skills & Knowledge:

• Advanced knowledge of medical terminology and pharmacology, ICD-10-CM/PCS coding, MS-DRGs, APR-DRGs, POAs, HACs, PSIs
• Advanced knowledge of documentation standards and improvement methodologies
• Knowledge and use of grouper and encoder systems, 3M/Nuance Cl integrity preferred
• Knowledge and use of EMR’s, Epic/Power chart preferred
• Strong organizational, analytical and problem-solving abilities and techniques
• Client relationship and management skills
• Strong proficiency in Microsoft Office
• Ability to work independently in a remote environment

About Pena4
Pena4 is a global provider of healthcare, revenue cycle, and technology solutions focused on innovation and human expertise. With a presence across the USA, India, Canada, and Puerto Rico we deliver high-quality services in medical billing, coding, consulting, and integrated technology solutions. Our mission is to blend technology with human expertise to boost client outcomes and create lasting value.

Why Join Us
You will work alongside passionate teams, gain valuable skills, and help shape how Pena4…